靜脈血栓 Venothromboembolism (VTE)
  • 通常Proximal DVT / PE就要用藥,病情嚴重才考慮溶栓(PE)/取栓(DVT),IVC filter目前證據等級低
  • 分為Provoked / Unprovoked,決定用3-6個月或更久
  • Distal DVT和Subsegmental PE是否用藥仍待討論
  • 常見用法 

               (1) DOAC

               (2) 先UFH / LMWH再DOAC

               (3) 先UFH / LMWH再Wafarin

  • 用藥前考慮

               (1) 癌症

               (2) 腎功能

               (3) 懷孕

               (4) 其他凝血異常


Unfractioned heparin (UFH)

  • 較易產生HIT(heparin-induced thrombocytopenia)、頻繁監控血中濃度
  • 使用時機:ESRD、需要隨時停藥或逆轉(protamine)

Low molecular weight heparin (LMWH)

  • Cancer-related VTE 的第一線藥物,但要打針

Warfarin (Cofarin)

  • 要和UFH/LMWH重疊至少五天,抽血監測 INR 2.0~3.0
  • 效果和DOAC相仿,但出血機率更高,且作用慢、需監測濃度

Direct oral anticoagulants (DOACs)

  • Edoxaban (Lixiana): higher risk of bleeding (esp. gastric cancer)
  • Rivaroxaban (Xarelto): monotherapy
  • Apixaban (Eliquis): monotherapy
  • Dabigatran (Pradaxa): no evidence in cancer patients
腎上腺功能不全 Adrenal insufficiency (AI)

Primary adrenal insufficiency (Addison's disease)

Autoimmune adrenalitis (often anti-21-hydroxylase)

  • Isolated adrenal insufficiency
  • Polyglandular autoimmune syndrome type I (autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy, APECED syndrome)
  • Polyglandular autoimmune syndrome type II

Infectious adrenalitis

  • Tuberculosis
  • Disseminated fungal infection: esp. Histoplasmosis and Paracoccidiodomycosis
  • HIV infection and AIDS: more often due to opportunistic infections
  • Others: syphilis, African trypanosomiasis

Hemorrhagic infarction/thrombosis (a/w meningococcemia (Waterhouse-Friderichsen syndrome); a/w PsA(?))

Metastatic disease (esp. lung, breast, stomach, colon ca, and lymphoma; often missed!)

Drugs (usually compensated by increased ACTH secretion)

  • Inhibit cortisol biosynthesis: etomidate, ketoconazole, fluconazole, metyrapone, suramin
  • Accelerate the metabolism of cortisol: phenytoin, barbiturates, rifampin
  • Adrenocorticolytics: mitotane

Severe inflammatory disease


Secondary adrenal insufficiency

Panhypopituitarism

  • Large tumors or craniopharyngiomas
  • Infectious disease, e.g. tuberculosis or histoplasmosis
  • Infiltrative disease or lymphocytic hypophysitis
  • Head trauma
  • Large intracranial artery aneurysms
  • Hypotention, e.g. Sheehan syndrome
  • Hemorrhage, e.g. pituitary apoplexy

Isolated ACTH deficiency (autoimmune or genetic causes * too rare!)

Familial cortisol-binding globulin deficiency

Traumatic brain injury

Drugs

  • High-dose progestins, e.g. megestrol acetate
  • Opiates
  • Immune check-point inhibitor


Tertiary adrenal insufficiency

Abrupt cessation of high-dose glucocorticoid therapy

Correction of hypercortisolism (Cushing's syndrome)

Others: tumors, infiltrative diseases such as sarcoidosis, cranial radiation


                                                                                                                                                         


Clinical manifestations - dependent on:

* rate * extent of loss * mineraocorticoid function * degree of stress


Adrenal crisis

Caused by either mineralocorticoid / glucocorticoid deficiency

Manifestated by shock, anorexia, N/V, abdominal pain, weakness, fatigue, lethergy, fever, confusion, coma, *abdominal/flank/back/lower chest pain*

Precipitated by infection, stress, insufficient replacement, acute gland destruction


Chronic primary adrenal insufficiency

Symptoms of mineralocorticoid / glucocorticoid / (women) androgen deficiency

  • Secondary/tertiary: normal minerocorticoid function

Manifestated by fatigue, weight loss, GI upset, muscle and joint pain, pubic hair loss and amenorrhea in women

  • More specific: skin hyperoigmentation, postural hypotension, salt craving
  • Laboratory findings: hyponatremia, hyperkalemia, anemia